Frontal fibrosing alopecia

Frontal fibrosing alopecia describes hair loss and scarring in the frontal region of the scalp.

What are its features?

Frontal fibrosing alopecia usually affects post-menopausal women over the age of 50. It is characterised by usually symmetrical band of hair loss on the front and sides of the scalp, and loss of eyebrows. The edge may appear moth-eaten, and single "lonely" hairs may persist in the bald areas.

The skin in the affected area usually looks normal but may be pale, shiny or mildly scarred without visible follicular openings. At the margins of the bald areas, close inspection shows redness and scaling around hair follicles.

What is the cause of frontal fibrosing alopecia?

The exact cause of frontal fibrosing alopecia is unknown. It is thought to be due to disturbed immune response to some component of the intermediate-sized and vellus scalp hair follicles. The onset after menopause suggests there may be a hormonal component.

Skin biopsy findings

A skin biopsy examination in the laboratory helps in making the diagnosis. The newly affected hair follicles are surrounded by a lichenoid pattern of inflammation associated with scarring. The histopathological features are identical to those of lichen planopilaris.

Course and prognosis

Usually frontal fibrosing alopecia is slowly progressive. In a few patients it stabilises after a few years.

Since 2009, there have been several reports of the use of the antidiabetic agent pioglitazone (off-label) for the treatment of frontal fibrosing alopecia. Its efficacy has varied. In one report(1), 3 out of 4 treated patients had reduced symptoms, inflammation, and disease progression. Side effects include ankle swelling and weight gain.